Indiana Community Health Worker Symposium Indiana State Department of Health Monday, October 15, 2012 Sherry E. Gray, Director Jane Clawson, Health Access Worker How Health Access Workers Measure Outcomes for Community Based Care Coordination

Why We Do What We Do: “ A Whole Different Kind of 99%-ers” 2 1% = for 25% of health care costs Avg,$100,000 per year in ER, hospital, MD visits and RX 5% of patients =50% of all healthcare spending consume 55% of all healthcare services Contributing factors: chronic disease (diagnosis, treatment, management); health care coverage; financial resources; provider access; system complexity; social support

Why We Do What We Do: Indiana’s Vulnerable Citizens (A Snapshot) million Hoosiers 21% of Hoosiers live in poverty 1.1 million Hoosiers = some type of Public Assistance (i.e. Medicaid coverage, etc.) 180% Increase in Food Stamp Recipients in the last 10 years 800,000+= Medicare Coverage 800,000+ = Uninsured 47% of Hoosier public school kids receive free/reduced lunch

Indiana’s Health: Hoosier Snapshot 4 High % teens giving birth Low Birth weight % Overweight Heart Disease High Blood Pressure Diabetic Smokers Model that tends to be treatment/procedure oriented vs. preventative health/wellness/disease management oriented….

Why We Do What We Do: Opportunities: 5 Provide/increase access: “the 5 rights” Right Care Right Time Right Place Right Provider Right Payer Quality, evidence-based clinical/public health care is provided consistently to all Become better stewards of existing resources: both human and financial: minimize duplicative and/or repetitive processes and services Work with key partners and stakeholders to “own” this work together: as a community Demonstrate outcomes that make a real & observable impact (documented!) Meaningful differences/improvements in the lives of our friends, families and neighbors

Who We Are: Rural and Urban Access to Health (RUAH) 6 Purpose: To connect our friends, family, and neighbors to a comprehensive, integrated delivery network of health, human and social services resulting in improved access and removal of barriers to needed resources. Meaning and Mission: The word ruah, in yiddish means “Breath of Life”. The Goal? …to breathe new life into a health care system to better serve our most vulnerable community members

How We Got our Start: (a little history) 7 RUAH Partnership initiated: 2000 SV Health Inpatient, Outpatient medical care provider Indiana Health Centers, Inc. Federally Qualified Health Center (FQHC) Health and Hospital Corporation of Marion County County Health Department ADVANTAGE Health Plans, Inc. Insurance Provider (public and private plans) Butler College of Pharmacy, later added Pharm D students Pharmaceutical Assistance Program (PAP) Consultation Project Management/Oversight Community Interface Groups: local partner groups responsible for program implementation. Health centers, health departments, physician offices, civic groups, and health, human and social service agencies Funded by HRSA, Ascension Health from Additional private funding through the Anthem Foundation: establish 3 additional sites Sustained through local hospital funding and captured reimbursement through enrollment efforts

How We Do our Work: Our Resources HAW’s 6.5 MAC’s Direct Hires Community-agency based System Administrative Support 1 Health Access Manager 1 Operations Facilitator 1 Administrative Assistant 3 Language Access Staff 1 System Director Annual Budget $1.1 million

What We’ve Done So Far: Program Outcomes 9 Four community programs expand to Eight community programs Outcome Focused: Pathway Model Integration 5 Pathways implemented Data reporting effective 9/11 Used to count what we did “to/for” clients vs. outcomes! AHRQ Innovation Site Community Care Coordination Learning Network Site National Institute of Health Research Partner Indiana CHIPRA grantee Madison County Community HUB $39.8 million worth of low/no cost drugs provided Language Access 1253 interpreters trained through Bridging the Gap 1094 documents translated Integration with Federal, State and County Stakeholders

How We’ve Changed: Moving from a Volume Based to an Outcome Based Measurement Model Our 1 st 8 years: 1. Counted number of encounters 2. Recorded initial vs. follow up visits 3. Reported EVERY thing we did 1. To 2. For 3. With Our Clients 4. High Volume; Low Outcome Measurement 10 Our last two years, and moving forward: 1. Record number of clients referred to us for a baseline 2. Collect Barriers 3. Report Pathways 1. Opened 2. In-Progress 3. Completed 4. Incompleted 4. Starting the Benchmarking and ROI Process

How & Why We Decided on PATHWAYS: 11 1.Best Practice Research 2.Communicating with our “sister programs” 3.Assessing how other disciplines were doing their work and/or changing how they viewed their work 4.“Scanning” the environment for current and future changes 5.Address how all of the above fit with our goal, our mission and our sustainability 1.Best Practice Research 2.Communicating with our “sister programs” 3.Assessing how other disciplines were doing their work and/or changing how they viewed their work 4.“Scanning” the environment for current and future changes 5.Address how all of the above fit with our goal, our mission and our sustainability

12 Focusing on Outcomes

How We Design our Pathways: 13 1.Review and Discuss Available Data and Community Input 2.Prioritize Areas of Focus 3.Discern and Decide the Desired Outcome (start with the end goal in mind) 4.Agree to the Initiation Step for the Pathway (with whom and how does a specific Pathway get started) 5.Identify the KEY steps that are consistently taken to work towards a successful outcome 6.Identify barriers to be collected (and later used as a way to problem-solve) 7.Build the Measurement Tool 8.Start the Work 1.Review and Discuss Available Data and Community Input 2.Prioritize Areas of Focus 3.Discern and Decide the Desired Outcome (start with the end goal in mind) 4.Agree to the Initiation Step for the Pathway (with whom and how does a specific Pathway get started) 5.Identify the KEY steps that are consistently taken to work towards a successful outcome 6.Identify barriers to be collected (and later used as a way to problem-solve) 7.Build the Measurement Tool 8.Start the Work

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15 The Pathways Model: SVH RUAH Medical Home Medical Referral Pregnancy Social Services Enrollment

HAW MONTHLY REPORT September 2012 Source of Referral Field Based283 Clinic/Office134 Hospital42 Emergency Room38 Med Assist10 SPN4 Total511 Participant Visit Location Home52 HAW Office384 ER7 Community22 Clinic/MD Office31 Total496

HAW MONTHLY REPORT September 2012 Financial Class Uninsured337 Private Insurance43 Medicaid78 Medicare37 Other7 HIP2 VA Health Benefits1 Total505 Initial vs. Follow-up Visits Followup Visit328 Initial Visit168 No Purpose Listed15 Total511

18 HAW MONTHLY REPORT September 2012 Open Pathways Enrollment116 Medical Home29 Pregnancy0 Medical Referral41 Social Services241 Total427 Pending Pathways Enrollment97 Medical Home26 Pregnancy0 Medical Referral30 Social Services56 Total209

Completed Pathways Enrollment70 Medical Home23 Pregnancy0 Medical Referral46 Social Services236 Total375 Completed Historical Pathways Enrollment947 Medical Home694 Medical Referral327 Pregnancy23 Social Services2734 Total4725 HAW MONTHLY REPORT September 2012

Incomplete Pathways Enrollment321 Medical Home38 Pregnancy8 Medical Referral20 Social Services47 Total434 HAW MONTHLY REPORT September 2012

Why We are Planning for The Future: 24 Pay for Performance Initiatives State -Federal Insurance Exchanges State -Federal Insurance Exchanges

How We Plan To Contribute: 25 Un/underinsured community members can receive care “sooner vs. later” Consistent and familiar care is provided along with follow up & follow through: treatment is across time and not episodic Resources are used as effectively as possible, including: Human Providers, Practitioners, Care Coordinators, Administrative support, etc. Financial Reimbursement, Funding, Cost-Avoidance, “Write-Off’s” Technological Connecting Information in a timely, meaningful way Support (wrap-a-round) Services Connecting medical treatment, public health practices, & psychosocial principles Vital connections are made Integrate and coordinate care not duplicate and replicate care “Best Practice” Learning's are shared; and solutions are not “re-created”

Questions? 26